| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
523 |
432 |
$12K |
| D0272 |
Bitewings - two radiographic images |
366 |
301 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
159 |
91 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
308 |
251 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
207 |
168 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
364 |
302 |
$2K |
| D2140 |
|
93 |
52 |
$2K |
| D2160 |
|
20 |
14 |
$578.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
26 |
$201.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$175.50 |
| D1999 |
|
112 |
109 |
$101.57 |